Diabetes in Pregnancy Hyperglycemia in Pregnancy - PowerPoint Presentation

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Diabetes in PregnancyHyperglycemia in Pregnancy

Prof Vinita DasDean Medical FacultyHOD Ob/GynKGMU, Lucknow

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Disclaimer

This presentation and slides are for educational purpose for teaching & training of undergraduate medical students

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Objectives of Session

What is GDM?How to diagnose and monitor during pregnancy in India?Effect of GDM on pregnancyEffect of GDM on fetus & neonateLong term consequencesManagement during Labour

Postpartum contraception

Pre-conception counseling

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Diabetes a Global PandemicPrevalence very high in Asians

Global Prevalence is 1-15%Incidence gradually increasing in younger population

Pregnancy is a Diabetogenic state – Hyperglycemia in pregnancy (HIP) quite common

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Diabetes & PregnancyPregnancy in Pre-existing Diabetes

Gestational Diabetes Mellitus (GDM) Prevalence in India 14-17%

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Changes in CHO metabolism during Pregnancy

Pregnancy is a diabetogenic state

There is a state of

increasing insulin resistance

(

due to Cortisol & placental secretion of HPL)

Higher insulin resistance also results into compensatory Hyperglycemia

Higher levels of

Estrogen & Progesterone during pregnancy

cause pancreatic B cell hyperplasia & hypertrophy resulting into

hyperinsulinemia

Glucose diffuses faster across the placenta to be used by fetus

Creating a state of

F hypoglycemia

(Accelerated starvation & catabolism) and

PP hyperglycemia

(facilitated anabolism)

State of accelerated starvation leads to higher free fatty acid production to be used by mother for energy

Low renal threshold of glucose & increase GFR leads to glycosuria

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Physiological changes during pregnancy

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Conditions that enhance IR overweight, obesity, PCOS, excess weight gain, offspring of GDM mother

Conditions compromising ability to increase insulin secretion – low birth weight, poor early life nutrition, stunting

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Risk factors for GDMAge > 25

Obesity (BMI ≥ 25) and Metabolic SyndromeHR ethnicity (South Asians, Mexicans, Blacks etc)Diabetes in first degree relativePCOSPrevious GDM/glucose intolerancePrevious macrosomic baby

Previous poly-hydramnios

Previous congenital malformed newborn

Previous unexplained perinatal loss

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Gestational Diabetes MellitusGlucose intolerance of any severity with onset or first recognition during pregnancy

Recommended in India - Universal screening at first antenatal examination in all pregnant womenIf woman comes late in 3rd trimester for the first time, test to be done

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DIPSI Test – Single step test

75 gm of glucose in 300 ml of water to be taken irrespective of meal intake After 2 hour Glucometer sampling done Blood sugar values ≥ 140 mg% is diagnostic of GDMIf report is negative, test to be repeated between 24-28 weeks gestation There should be 4 weeks interval between 2 tests

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DIPSI Criteria for Diagnosis of GDM/DM

2hr Plasma Glucose after 75 gm Glucose

irrespective of meals

In Pregnancy

Outside Pregnancy

>200 mg/dl

Diabetes

Diabetes

>140-199mg/dl

GDM

IGT

120-139mg/dl

GGI (gestational glucose intolerance)

<120 mg/dl

Normal

Normal

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Effect of GDMMaternal

Pre-eclampsia 15-20% vs 5-7 % in non GDMPoly-hydramniosPreterm deliveryOperative delivery

Perineal

trauma

Infections

Keto

-acidosis

Risk of future diabetes (60%)

Fetal & Neonatal

Fetal macrosomia

Prematurity

Birth trauma

Congenital malformations

IUD

RDS

Neonatal metabolic complications (hypoglycemia,

hyperbilirubinemia, hypocalcemia, polycythemia)Obesity & Diabetes in later life (20-30%) 4-8 times higher risk

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Fetal Complications

Fetal MacrosomiaIntrauterine fetal death (Hypoxia) Congenital anomaliesProposed factors associated with teratogenesis

in pregnancy with DM

Hyperglycemia

Hypoglycemia

Ketone body excess

Somatomedin

inhibition

Arachidonic

acid deficiency

Free oxygen radical excess

Factors must act before 7 weeks, so patients with poor

peri-conceptional

control, long standing diabetes & vascular disease, early 1

st

trimester GDM

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Fetal Macrosomia

Birth weight > 90th percentile> 4-4.5 KgComplicate 50% pregnancies with GDM and 40% with DM type I & II

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Congenital Malformations

Congenital malformations - most important cause of perinatal loss in pregnancy associated with DM2- 6 fold increase in major malformations in DM I & II

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Fetal congenital malformations in Diabetes in Pregnancy- Common in preexisting diabetes & GDM diagnosed in 1

st trimesterCNS malformations 10%AnencepahalySpina

bifida

Holoprosencephaly

Microcephaly

CVS anomalies 38%(most common)

VSD

Transportation of great vessels

ASD

Coarctation

of aorta

Cardiomyopathy

Single umbilical artery

Skeletal system anomalies 15%

Caudal regression syndrome

Sacral agenesis – most characteristic

Limb defectsRenal system anomaliesRenal agenesisHydronephrosisUreteric anomaliesGIT anomaliesDuodenal atresiaAnorectal atresiaSmall left colon syndrome

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Monitoring and Management of GDM

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Maternal Surveillance in GDM

Women education

Monitoring for hyperglycemia

Fetal surveillance

General Obstetric care

Special Obstetric care

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Glycemic Control

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Target Sugar Values in Pregnancy

F plasma sugar < 95 mg %2 Hour PP plasma sugar < 120 mg %

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Education for glycemic control

Glycemic goalsNeed for strict glycemic controlImportance of healthy diet and exerciseNeed for regular follow up

How to take metformin/insulin

Symptoms of hypoglycemia and its management

Use of glucometer

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After 2 wks

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Glycemia Monitoring

On MNT fortnightly till 28 wks ( 2hr PP)After 28

wks

weekly

On metformin / insulin + MNT - 7 times a day ideal or every third day till glycemic goals achieved (F & 2hr PP)

Thereafter every week

HbA1C at 6-8 weeks interval

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Diet plan according to Body Weight – KCal/Kg

Obese women : 25-30

Non-obese : 30-35

Underweight: 35-40

Dietary compliance is evaluated and reinforced during every hospital visits

Diet / MNT for all

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BMI & Pre-pregnancy weight decides weight gain goals

Pre-pregnancy Weight

Weight Gain during pregnancy in Kg

Normal

11.5 to 16

Underweight

12.5 to 18

Overweight

7 to 11.5

Obese

5 to 9

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Diet Composition

Carb 50 – 60%

Proteins 10 - 20%

Fats 25 – 30%

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Glycemic

index

concept to be taught to women

The extent of rise in blood sugar in response to a food in comparison with an equivalent amount of glucose

CHO producing less rise in blood glucose and insulin are low GI foods

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Important tips for diet planning

Divide meal into 3 Major meals and 2 – 3 snacksEat at same timeAvoid overeating Avoid fasting

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General tips

Avoid fried foods

Recommended steamed, boiled or sauté food

Whole fruits than juices

Fish/chicken over red meat

More fiber, salad and non- starchy veg

Whole grain cereals and pulses

Drink water, buttermilk, soups, soy milk

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Exercise

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What Exercises ?

Start 20 min/day, increase gradually to 45 min/day

Low resistance upper body exercise

Exercise for 15-20 min post meal

Avoid falls

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Pharmacotherapy Metformin / Insulin

When target sugars not achieved with MNT & Exercise in 2 weeks- Pharmacotherapy started

FPG > 95mg%

2hr PPBS >120mg%

or

Blood sugar values are high at

diagnosis

FPG >120 mg%

2hr PPBS >199 mg%

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Word of caution for Hypoglycemia

Blood sugar <70 mg/dL Drink 3 teaspoons of glucose powder (15-20 grams) or 6 teaspoon sugar dissolved in a glass of water

Take rest and avoid any physical activity

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Obstetric monitoring in GDM pregnancy

Routine ANC - Min 4 ANC for GDM well controlled on diet & no complications More ANC visits or as per need for GDM on insulin, uncontrolled blood glucose or other complication of Pregnancy Every 2 weeks in second trimesterEvery week in third trimesterMonitoring at each ANC maternal weight gain Abnormal fetal growth (macrosomia/growth restriction)

Polyhydramnios

BP and Proteinuria

Fundus examination

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Role of USG Early pregnancy scan for MSD & CRL

11-14 weeks scan for NTD18-20 weeks scan – TIFA (targeted imaging of fetal defects) Early prediction of PIH & IUGR24-26 weeks fetal Echocardiography29 weeks scan - AC for MacrosomiaFollow up scan at 32 & 36 weeks for fetal growth

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Antepartum Fetal Surveillance

Daily fetal kick count in third trimesterFetal NST and/or Biophysical profile as per needDoppler flow studies specially when associated with PET and IUGR

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Role of Antenatal steroids

Delayed fetal Lung Maturity in GDM pregnancyWoman requiring early delivery needs antenatal steroids Injection Dexamethasone 6 mg IMI 12 hourly 4 doses

Steroids are hyperglycemic agents

More vigilant monitoring of blood glucose for next 72 hours to one week

Adjustment of insulin done with each meal

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Mode & Time of Delivery

Primary goal is to have normal healthy newbornConcerns – Risk of Delayed lung maturity

Unexplained IUD & SB more after 36 weeks

Macrosomia

RDS

Vaginal vs cesarean delivery depends on extent of glycemic control and associated obstetrical problems

Women on diet control for spontaneous onset of

labour

Elective

labour

induction is controversial with no proven benefit

Women on insulin should deliver at 38/39 weeks

Cesarean section around 36 weeks for uncontrolled GDM on insulin

Elective LSCS for

fetal

weight > 4.5 Kg

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Intrapartum Considerations

These women are predisposed to infections so strict asepsisPer vaginal exams to be restrictedCPD to be properly assessedEarly decision of cesarean to be taken in case of prolonged labour

Continuous electronic monitoring is recommended as there is increased risk of fetal distress

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Labour management

When patient goes into spontaneous labour or planned for induction or LSCS – F blood sugar to be sentMorning dose of Long acting insulin to be withheld

Target blood sugar values in Labor is between 70 to 110 mg%

Blood sugar to be checked hourly

Urine sugar and ketone to be checked 2 to 4 hourly

Elective LSCS to be done as first case in morning

Regional

anaesthesia

is preferred

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Glycemic control during Delivery

Blood Glucose

Insulin/IV Fluids

60-90 mg/dl

5% GNS – 100 ml/hr

90-120 mg/dl

NS or RL – 100 ml/hr

120-140 mg/dl

NS or RL – 100 ml/hr plus

2-4 unit of regular insulin every hr

140-180 mg/dl

NS or RL – 100 ml/hr plus

6 unit of regular insulin every hr

> 180 mg/dl

NS or RL – 100 ml/

hr

plus

8 unit of regular insulin every

hr

Goal of intrapartum management is

to maintain

normoglycemia

in order

To prevent neonatal hypoglycemia

, capillary

hrly

monitoring is needed

Target values are 70-110 mg/dl

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Post partum Management

Marked decrease in insulin requirement in first 24-48 hrs post partumNeonate monitoring for hypoglycemia & respiratory distress ( Blood sugar < 45 mg% cut off for neonatal hypoglycemia)

OGTT done 6 weeks post partum with 75 gm Glucose ( Target values FBG < 100 mg%, 2

hr

PP BG < 140 mg%)

Lifestyle modification with diet & exercise and weight reduction

POP, Barrier contraception, IUCD all can be used as post partum contraception

Low dose COC after 6 months

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Long term Consequences

Higher chances of (50-60%) early dev of Type II DM & CVD in woman Higher chances (30-40%) of dev of repeat GDM in subsequent pregnancyHigher chances (20-30%) of early dev of type II DM and CVD in off springs

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Pre-conception counseling

Pre-gestational diabetic becoming pregnant (.2-.3%)

High risk of end organ damage

Higher risk of

cong

malformation & IUD

Should be a planned pregnancy

Emphasize need for regular follow up and compliance

Evaluation of end organ involvement

Retinopathy requiring laser therapy should be offered MTP

Women with significant impaired renal function (

S.creatinine

> 3.6 mg%) - should be offered MTP

To be shifted on Insulin if on oral drugs except if on metformin

Dietary advice

HbA1C should be < 6.5 before conception

F plasma Value < 100 mg%, 2 hr PPP glucose < 140 mg%Folic acid supplementation –peri-conception

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Early diagnosis & Proper management & follow up of women has the potential to prevent Diabetes in two generations

Strict glycemic control is key for successful outcome

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Thank you